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Bunch’s California Medical Provider Networks (MPN) Employer Presentation. Created 6-07. Purpose of the Presentation . Address MPNs with employers Provide overview of services Define components of the MPN Provide training materials Questions and comments.
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Bunch’s California Medical Provider Networks (MPN) Employer Presentation Created 6-07
Purpose of the Presentation • Address MPNs with employers • Provide overview of services • Define components of the MPN • Provide training materials • Questions and comments
California Senate Bill 899 – Medical Provider Networks (MPN) • Overview of the regulations for clients to implement the MPN • Further details and summaries of SB899 can be found on the DWC website at www.dir.ca.gov/dwc • Effective April 19, 2004 - California Senate Bill 899 was signed to allow the implementation of the Medical Provider Networks (MPN) on or after January 1, 2005 • November 2004 - The Division of Workers’ Compensation (DWC) enacted emergency regulations for the MPN
What is an MPN? • An MPN is an entity or group of providers established by an insurer or self-insured employer, and approved by the administrative director of the CA DWC, to treat workers who are injured on the job.
Key Points of Regulations • Requires the network to be approved by the DWC • Directs to the network for all workers’ compensation injuries • Directs to an initial treating provider at the onset of injury and requires referrals in-network for the life of the claim • Includes point of entry physicians such as family practice, general practice, internal medicine, occupational medicine and industrial walk-in clinics • Allows conditions to use non-network providers for Transfer of Care (TOCP) or Continuity of Care (COCP) or when specialties are not available within the MPN
TOCP Conditions • Acute - The treatment for injury or illness will be completed in less than 90 days. • Serious or chronic - Injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment. The MPN allows treatment with the injured worker’s current doctor for up to one year, until a safe transfer of care can be made. • Terminal - An incurable illness or irreversible condition that is likely to cause death within one year or less. • Pending Surgery - Surgery or other procedure that has been authorized by the employer or insurer that will occur within 180 days of the MPN effective date.
COCP Conditions • Acute - The treatment for injury or illness will be completed in less than 90 days. • Serious or chronic - Injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment. The injured worker’s doctor may treat for up to one year until a safe transfer of care can be made. • Terminal - An incurable illness or irreversible condition that is likely to cause death within one year or less. • Pending Surgery - Surgery or other procedure that has been authorized by the employer or insurer that will occur within 180 days of the MPN effective date.
Your MPN Includes • A comprehensive mix of physicians through the selected network • State-wide coverage • Directory services for initial treatment & referrals • Utilization review according to ACOEM treatment guidelines • Procedures for the following: • Employee notification • Transfer of care (TOCP) • Continuity of care (COCP) • Second & third opinions through the claims examiner
Employee Notification Employer must notify all employees within 30 days of implementation, upon hire and at the time of injury Pre-designation Procedure Eligible employees can pre-designate a medical provider under specific conditions Transfer of Care Procedures Employees with existing claim must be notified of employer’s intent to transfer care into the MPN Notice will define conditions under which treatment with a non-network provider may continue Decisions regarding cases eligible for Transfer of Care are made with case manager and adjuster evaluating cases concurrently Medical Provider Networks - Components
Continuity of Care Procedures Employees with existing claim must be notified if current treating provider terminates from the MPN. Notice will define conditions under which treatment may continue with the same provider Decisions regarding cases eligible for Continuity of Care are made with case manager and adjuster evaluating cases concurrently Second and Third Opinion Process Injured worker has the right to dispute the treatment or diagnosis of the treating provider Second and third requests for medical opinions are permitted Process is exhausted upon fourth request Injured worker is then referred to the DWC for an independent medical evaluation Medical Provider Networks - Components
What are the Access Standards? • For easy access to treatment, the network provides the following: • Primary care and a hospital for emergency care within 30 minutes or 15 miles of each employee's residence or workplace. The appointment must be available within 3 days of request for services. • Specialists care within 60 minutes or 30 miles. The appointment must be available within 20 days of request for services. • Access to non-network services when specialties are not available in-network or when certain conditions exist • See TOCP and COCP
Key Points of Regulations • Employee Notification • Employer must notify all employees within 30 days of implementation upon hire and at the time of injury • Materials available • Employee notification letter • Pre-designation procedure • Eligible employees can pre-designate a medical provider under specific conditions • Transfer of Care Plan (TOCP) • Notices sent to an injured worker who has an existing WC injury prior to the implementation of the MPN. The notice to the injured worker will affirm the employer’s intent to manage the case under the MPN and the conditions to allow continued treatment with the non-network provider.
Key Points of MPN Regulations • Continuity of Care Plan (COCP) • Notices sent to an injured worker providing notice that their treating provider has terminated the MPN and the conditions to allow continued treatment with the non-network provider • Second & Third Opinion Process • A process to allow the injured worker to dispute the treatment or diagnosis of the treating provider. Injured workers are allowed a second and third request for another opinion. Upon the fourth request, the process is exhausted and the injured worker is referred to the DWC for an IMR.
Employer Responsibilities • Distribution of Employee Notification Letter regarding the MPN • Completion of First Report of Injury Report • Upon implementation • Time of hire • Date of injury
Regulations Supported by Bunch and TPA • Transfer of Care Plan (TOCP) • Continuity of Care Plan (COCP) • Second and Third Opinion Plan
Sample Training Materials • Employee notification guide • Employee presentation
